The Recertification Process: Insulting and Irrelevant

John M. Mandrola, MD; Edward J. Schloss, MD


June 22, 2015

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John M. Mandrola, MD: Hi, everyone. This is John Mandrola, with on Medscape. I'm here in Boston for the Heart Rhythm Society (HRS) 2015 Scientific Sessions.

I'm pleased to have as my guest Dr Jay Schloss, who is director of cardiac electrophysiology at the Christ Hospital in Cincinnati. Jay is a friend of mine. He's an electrophysiology colleague, and we are here to discuss the American Board of Internal Medicine (ABIM) maintenance of certification (MOC) debate. Welcome, Jay.

Edward J. Schloss, MD: Thanks, John. It's good to be here.

Dr Mandrola: We just came back from a debate with Dr Zipes and others about MOC, and one of the things that came up was that society hasn't trusted us to self-regulate ourselves as physicians. Let's start with that.

Dr Schloss: We've got this enormous responsibility and privilege, that people will tell us things and we can touch their bodies and we can put a knife to their skin. That's an awesome responsibility. With that, we have to do it right. There's no doubt that we need to hold physicians accountable.

It's a little insulting to say that, because you and I are accountable every day with every patient that we see. We're accountable to the patient; we're accountable to the patient's family; and we're accountable to the insurers, and to our nurses who watch over our shoulders. There are a lot of eyes on us right now. The process of self-regulation happens somewhat organically by the fact that you just can't do the job without people watching you.

The notion of self-regulation—how can we actually get another set of eyes above us to find out whether we're doing things right? I think that's open to question. We are watched. Do we need to be watched a little bit more closely than we currently are? There certainly are some bad apples, and it would be nice to find a way to ferret those folks out.

The Recertification Process

Dr Mandrola: I'm especially interested in hearing from you about your recent experience with ABIM because I'm set to recertify next year, but you've recertified in cardiology this year. Maybe I'll ask you about the ABIM certification that you just went through.

Dr Schloss: As you know, I did my 20-year recertification. I'm a clinical electrophysiologist, mainly based on device therapy and heart failure. I've got a very viable career that's been rolling for 18 years now. I don't do a lot of general cardiology, but I still have a taste for that.

This year when the cardiology boards were looming, there was an enormous amount of material I was going to have relearn. Much of it has changed, and much of it has little relevance to what I do right now, but as a good soldier I went ahead and did it.

You get the study modules and I'd go to Starbucks, which is my go-to place to get away from home distractions. I'd get there and look around; I'd be the only 51-year old there. There would be a bunch of people with laptops—they're all students. There aren't any airline pilots there; there aren't any lawyers there. There are no other professional 20-year recertification people that I can find. This is unique to doctors.

I'd just sit there and go back to old med school days and start cramming in information. As I've said to you before, I think it's pretty clear that doctors are selected as being capable of taking enormous amounts of information, cramming it into their minds, memorizing it, and then regurgitating it on an exam. We wouldn't have gotten this far were that not the case. We've got the goods to do that. It's not a lot of fun, but that's what you do in the study process.

While that's going on, other things, both personal and professional, unfortunately have to take a backseat. I lost a lot of time sitting in there for many, many hours, pulling in this information, which is honestly of limited relevance.

Dr Mandrola: So let me just make you take a stand there. This is one of the major criticisms of the ABIM MOC process—that it's not relevant. You did not find it relevant to your practice?

Dr Schloss: Huge swaths of what I relearned is not relevant to my practice.

Defining 'Good Doctors'

Dr Mandrola: What do you say to the general public who says, "We need some way to know that our doctor is a good doctor." I exchanged tweets with a patient on Twitter recently. She asked me, "How do I know whether this is a good doctor?" Is the ABIM the brand to tell her that we are capable?

Dr Schloss: Let me give you just a quick story that goes along with that. There are a lot of things we learned along the way before we got an MD or the initial board certification. One of them is biology, or biochemistry.

My daughter is taking AP biology. Many people would say that these courses have a lot of relevance to medicine, that people who take them are going on to become doctors. I flipped through the back of one of those exams. I would not get anything right. I would fail. I would get a 1 on the AP exam; maybe they grade lower, I don't know. It isn't relevant anymore, 100%.

For me to learn, to be tested in a closed-book environment on auscultation of complex valvular heart disease—well, it's not something I do, so I don't have an imperative to continue to exercise my skills. My ears aren't very good. Especially in the testing environment, not just to hear it but to have to describe what you did hear and then identify a patient scenario, I find that very frustrating. It isn't relevant to me any more than the biology is.

Closed-Book Exams Are Old School in the Digital Era

Dr Mandrola: What do you feel about the closed-book exam process and its relevance to this digital era, when we can just look things up?

Dr Schloss: It's incredibly old school, and I think maybe they're starting to wake up and realize that. Especially in a recertification process for somebody who is already established in practice, this notion that I'm going to have to memorize and then regurgitate in a secure environment is, frankly, a little insulting.

The current way we practice now, if I'm sitting at the bedside—and this happens all the time, I've got my computer with me—and I'm not sure about something, I'm not going to draw on the memory that I had from studying for boards. I'm actually going to go online and do a search and find it out. If it's outside of my area of expertise, I'm going to ask for help. We work in teams. We have other experts who handle these things.

For anyone to represent themselves as being an expert in complex valvular disease on the basis of taking this exam is a little naive. Quite frankly, if people think they know it and they really don't, that might be even a little bit dangerous.

The testing environment itself is truly painful and insulting. I'm 51 years old. I've got an established practice. To arrive at a test facility and be asked to empty my pockets and put the contents in a locker—they literally have you do this, you reach into your pockets, and you empty your pockets to prove you have nothing in them. You then sit in a quiet room. There are video cameras trained upon you, and you sit with a bunch of people taking accounting exams and other things like that, in front of a screen, checking off A, B, C, D, or E for three 2-hour sessions. I'm not sure what that has to do with clinical practice, honestly.

Dr Mandrola: It seems kind of childish.

Dr Schloss: Very childish. You have to swallow your pride and just do it, because that's what they say to do.

Dr Mandrola: How do you think the ABIM got themselves into this situation? How do you think this transpired? We always used to just get in line and do what we do, and now there is this uproar.

Dr Schloss: People have written about this, and I agree, doctors are getting stretched in a lot of different directions right now. There's a lot of pressure on us. You're a clinician. You want to show up, look your patient in the eye, and provide them the best-quality care. That's the passion that drives you. It's getting harder and harder and harder to do that. The MOC is just one other thing that got piled on.

It becomes apparent when you're asked to do something else, there's a breaking point where you say, I was with you before but now I'm filling out these silly polls, I'm doing additional testing modules on top of the enormous amounts of continuing medical education (CME) that I already do, and it's intruding on my clinical care.

Then you start looking at it more closely, and you realize these guys are out of touch. There's no evidence to back it up. Then you start digging into the financial issues that our friend Wes Fisher has done an admirable job on, and you start thinking that this whole thing doesn't make a lot of sense.

I've been in practice for a long time, and this is the first time I've seen doctors band together this much over a common cause. It's refreshing to finally see people speaking up.

Supervision and Ensuring the Public Trust

Dr Mandrola: This coming together is really remarkable. I see it as one of the major things coming out of this. You have some very interesting ideas on how we could improve things.

One of the criticisms of critics of ABIM is, if not ABIM, then what? Tell us your thoughts on supervision and ensuring the public trust.

Dr Schloss: I'll try to be succinct. Remember back to when we were residents—how did you know if a doctor was any good or not? Well, you would work alongside them, your senior resident and the intern. You could tell whether they were good or not good; the reason is, you shared the same patient.

One of the things I noticed when I got out into practice is that I can't tell. I have a really hard time telling the good doctors from the bad doctors, and the gradations between good and bad. And the reason is, I don't have access to their information. I don't see their records. I don't see their patients. I don't see their interview style. Looking simply at patient results, sometimes you can tell, but most of the time, you can't tell—which is the only way we're being evaluated right now, on the basis of patient results.

There was a JAMA perspective[1] written by a couple of Harvard Business School people that I would encourage people to seek out and read. It's honestly one of the most naive things I've ever read about healthcare.

Dr Mandrola: It's in the recent JAMA.

Dr Schloss: I'm going to go on the record and say it was horrible. I'm sure these are very bright people, but they didn't seem to have a notion of what it is that we actually do. They compared doctors and processes with Toyota and assembly lines, and suggested the MOC process is a way to create that. This is not that at all.

The reason Toyota runs is because of a hierarchical supervision model and the ability of the people on the line to be able to speak up and create continuous process improvement. It's not a multiple-choice exam. You don't create a good auto factory by sending the workers to take a secure multiple-choice exam and then putting them in the factory with no supervision. That's not going to work.

Dr Mandrola: Right.

Dr Schloss: The supervision piece is the part that I find interesting. For many years, managing doctors had too much of the "herding cats" mentality. We're all independent contractors. We're not interested in hearing other people's opinions, and that's what got us into the mess—nobody wants to regulate us. If we can't regulate ourselves, then obviously somebody else has to.

Many of us are owned by a hospital; there is a hierarchical system. I depend upon the hospital to hire me and write my contract. If they added in a supervision piece, I would welcome that.

The chief of my department could take some of the ABIM money and shuttle it into paying a peer to supervise me, like the senior resident used to. He comes by the room and asks, "What are you doing today, Jay?" I'm doing a pacemaker. He looks at the chart and says, "I'm not sure I get why. There's a 3-second pause while sleeping; that's why you're putting the pacer in?" Well, I'm not going to do many more unindicated pacemakers when I know somebody is looking over my shoulder reviewing all the information, with the ability to interview the patient and hold me accountable. If you did that kind of supervision and ran it like a business, we could iron out a lot of these problems a lot better than multiple-choice exams would.

Dr Mandrola: At my hospital, we have a very strong peer-review process. What I get out of it is really amazing. There are 15-20 of us in the room. I wish the whole hospital staff could have the benefit of that local review.

Dr Schloss: Do you peer-review your complications, or interesting cases, or random cases? How do you do it?

Dr Mandrola: We peer-review cases that "fall out" in medicine (ie, concern about a potential quality issue is raised). We have gastroenterologists and cardiologists and everybody. So many interesting things come up in the discussion of the cases that fall out. We're trying to get the minutes out to the medical staff.

Dr Schloss: That sounds great. Unfortunately it takes time, and you have a limited amount of time. All of these other stressors suck away from that.

Professional Societies Competing With ABIM

Dr Mandrola: The ABIM is now facing some competition. There's another board coming about, and I think there will be competition from such professional societies as the American College of Cardiology (ACC) and the HRS. Do you think that the HRS or ACC is maybe in a better position than ABIM?

Dr Schloss: This is a tricky one. I do think so. We need clinicians who know how to practice to work on our certification process. If you look at the board members of the ABIM, they are not, by and large, people like me and you.

Dr Mandrola: Right.

Dr Schloss: I absolutely welcome supervision. I welcome being held accountable, but it needs to be by somebody who knows what they're talking about—someone who has walked in my shoes, understands patient care, and is invested in our world. I'm not getting that right now. ACC and HRS are better. There's a lot of work to do to get to that point.

I've been critical of some of the questions that were on the Adult Clinical Cardiology Self-Assessment Program (ACCSAP). If we're going to keep going down a pathway of being tested, it has to be better than what they're doing right now. But it's probably better than ABIM.

Dr Mandrola: Jay, thanks for coming by. Thanks for watching. This is John Mandrola from the on Medscape, signing off from Boston at the Heart Rhythm Society 2015 Scientific Sessions.


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